So because not only do I have insomnia, I also suffer from it, the most-recent in the chain of moderately alarmed sleep-adjacent professionals (the neurologist at Deer Creek) referred me to the Improve Your Sleep! class, which has been eating my Monday evenings over the last month.

The main feature of this class, in the eyes of the neurologist and my counselor, has been the CBT aspect of it. Apparently the number one thing that cures insomnia is CBT. So everyone was hopeful. (I had specified to the neurologist that I would in fact be running anything suggested in the CBT past my Supervisor and my therapist. Which was a good call to have made.)

It turns out that when Guide Dog Aunt loaned me a book on sleep a few years ago, the one that pointed out that there was not in fact any moral value to any specific sleep schedule, and that instead of saying stuff like "I'm lazy because I sleep until noon", one should look at it in terms of "My most productive hours are in the evening, and I schedule my life in a way that suits my sleep schedule" -- that general tool of re-framing the guilt and fear around sleep is in fact the very CBT that this class relies on. So, unfortunately, the CBT that I had hoped would be new information was not, in fact, new information at all. The book specifically addressed Negative Sleep Thoughts. The class then expanded the concepts of re-framing runaway negative thought chains in a better light, which is also a Fishmum trick that I've been teaching my little fishies and my partner...

The other main leg of this class is meditation and the relaxation response. I believe that I can trace my habit of meditative breathing in particular to the summer when I read ... some Heinlein book or other ... and thought that taking up meditation would be a grand idea. The latest that could have been was 1996. Then I formally took up meditation (and learned all of the techniques discussed in the meditation unit of this class) in 2001-ish, when I went to DeVry to get a degree in Holistic Massage join a coven. So depending how you slice it, I've been familiar with, and practicing, meditation for anywhere from fifteen to twenty years.

The main new information I got out of the class, in fact, was that sleep-maintenance insomnia was recently discovered to be associated with a sleep-time body temperature that has not dropped as it ought to for that part of the night. And I do, in fact, routinely overheat while attempting to sleep. Which means that if I'm in bed and even slightly think that I might not get to sleep soonish, I should immediately go and get the ice pack, and not try to be a hero.

Also, low doses of sedating antidepressants are also used as sleep medications. The instructor was down on this practice, because antidepressants are only good for people with depression. FUNNY THING, THAT.

Pretty much all the rest of the class was review, and (due to my internets research) I was often in possession of more detailed information than the instructor. I came to feel that I could probably have taught the class myself, given the curriculum.

The first class was pleasant enough. I think there were about ten of us. One woman came in late, and borrowed a pen from me. We had a pleasant chat while she was waiting for her husband to pick her up. She's sleep-deprived to the point that she can't safely drive, and caretaking for her autistic son has done a number on her sleep schedule and ability to stay asleep.

I reviewed the materials in the packets for the four weeks. The second week, the cognitive re-framing, was going to be hard, since the materials blithely suggested that "most people" could get away with abbreviated amounts of sleep with nothing more terrible than a loss of creativity and a bad mood. Pro tip: when your patient reports suicidal ideation and impulses tied to as little as one night of abbreviated sleep while under stressful circumstances (and the current Republican administration is nothing if not stressful circumstances) telling the patient that everything is probably going to be okay if they blow sunshine up their own ass is life-threateningly bad advice. So I realized that I had better sit next to the door in case I had to step out of the room.

During the second class, the instructor was trying to impress upon us the way that a poorly timed nap can fuck up your sleep schedule pretty badly. My friend said that this was going to be a problem for her: you put her in the car (as a passenger) and she passes out pretty much instantly.

"It should be easy to stay awake in the car!" said the instructor.

"It's hard."

"Well, life is hard."

At this juncture, I decided that the most constructive action I could take was going to be going and sitting in the hall for a bit (and angrily texting my partner). I came back in after about five minutes.

Later in the evening, the instructor planned to lead us through more meditation/relaxation, to include the rest of the class period. I abruptly realized that I did not actually feel that making myself vulnerable to and in front of this instructor was a good idea, and grabbed my stuff and left the building.

In the third class, I sat by the door. (My friend did not show up for this class, or the following week.) When the meditation/relaxation section arrived, I popped both headphones in and proceeded to listen to podcasts, and only emerged when that bit was done. At the end of class, I asked the instructor about the bits in the next one, saying without explanation that I would not be taking part in the relaxation exercise, and would likely leave the room. He said when the long one would be, and there would be another short one later.

In the fourth class (tonight), I sat by the door, and took a chair with me when I popped out for the duration of the exercise. The instructor came and fetched me when it was done. And I did other things for the short one.

I did ask, this time, what he recommended to keep you awake when the sleep pressure is high but it's a bad time for a nap. And if there were resources on being a millennial and not having a whole house to work with in terms of keeping stress out of your bedroom. (Do something loud. And, probably, somewhere.) I asked about next steps. He recommended the meditation class, or the anxiety class. "That really doesn't seem to be a recommendation geared for someone who has been practicing meditation for fifteen years," I said, smiling aggressively.

He recommended tai chi.

"That's really rather along the same lines," I said, still smiling.

There was a class evaluation form, which asked about how much we learned from the class, and how helpful it was. It was ... not.

So I'll be asking my GP, my counselor, and my psychiatrist about next steps, then. Now that I've taken this miserable class so they'll take me seriously.

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I admire you for the sheer cussedness and hard work it takes to put up with that crap. I know it's not f***ing optional because of the requirement to accept crap to get passed along to anything new to try, BUT you still did something pretty impressive. The longest I've put up with 'I could teach this' is a few hours at a time, and it wasn't medical.

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*realizes this story is more personally applicable than I want it to be* Gahhh and I dunwanna deal with the medical things or the sleep things of my own either *hides* oh noooo it even found me at the bottom of my cup of chamomile tea. *makes pillow fort* If I stay here long enough that's LIKE sleeping right?

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The part with the ice packs was useful, even though I did have to extrapolate the "and you can use the ice packs you're already using" bit from "people who wake up in the middle of the night may have higher temperatures than those who don't" part.

And apparently I have a very well-developed chain of associations leading to bedtime, and I shouldn't interfere with that now that I have that developed. But getting the random cruft out of my brain before bed is also a helpful habit, and I should integrate that better into my new bedtime routine.

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Waugh. That's horrible. That does not sound like an environment that is good for inducing vulnerability. Good for you noticing that.

I take a low dose of one of those sedating antidepressants for sleep (since other ADs keep me from sleeping for long enough, and keep me from going to sleep) and it is glorious. I sleep enough. I fall asleep within 20 min unless my brain is really on about something. I am awake in the morning (if I've slept enough). For people with depression, it's (ime) not a bad call.

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I've been taking low-dose tricyclic antidepressants to help me sleep for years. Every three - four years I rotate to a new one.

Amtriptyline is super effective--I hated it the first time around because it creates dry mouth. But having taken both lithium and Wellbutrin, my default hydration is so high that I'm loving the Amtriptyline this time around. 30mg at dinner.

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That sounds like the most miserable, most aggravating load of codswallop I have ever heard. (The class, I mean.)The one time I ever took one of those, the instructor at least gave out a quick questionnaire to see who knew anything about what was going to be discussed. I sort of tested right out of that class. But yours! Ugh.

Here's hoping something works out for your sleeping. (Is it just getting to sleep or is it staying asleep? Mine's trouble getting to sleep and then I can't stay asleep and then I wake up early early when I do manage to stay asleep. It's remarkable how you can want to stab your brain.)

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It used to be both. After shifting the timing of my melatonin to sunset/dinner and reducing the dosage (apparently .5mg [500mcg] is less likely to overload your receptors and leave you going "WEEEEEEEEE!" in the middle of the night), and getting a powerful incentive to be in bed at a certain predictable time every night courtesy of a certain partner (mmmm) (even though we don't share a bed yet), the going-to-sleep is no longer such a problem.

Then I can't stay asleep, except that then I *do* go back to sleep, and when I wake up then it's noon.

From an email to my prescribing psychiatrist:

I would not recommend that patients who have researched insomnia on their own and already made lifestyle changes be enrolled in this class, although the paper packets may contain some 5% or less of new information. Patients who have already studied relaxation and mediation may find up to half this class redundant. Patients with a history of trauma may find this class unsafe to participate in. I would not recommend that patients whose response to insufficient sleep includes suicidal ideation or impulses be enrolled in this class, *ever*.

Unfortunately, the CBT principles of reframing negative thoughts around sleep are something I've already been practicing for several years. I hadn't known that was what was meant by CBT.

At our next appointment, I'd like to discuss medication to address my continued inability to remain asleep.

From an email to that neurologist:

I've completed this class (it's now 4 weeks, not 5). I wanted to give you feedback to improve your recommendations for other patients. I would not recommend it for the following groups of people:

People who have researched insomnia and are following best practices, who practice meditation, and who have already learned to check their negative thoughts around sleep for accuracy and re-frame the inaccurate ones. This class is just above 101 level, and was a poor use of my time.

Patients whose response to as little as one night of insufficient sleep includes suicidal ideation or impulses: the CBT portion of the class is unsafe for anyone in this situation to try. These patients might try working on personalized CBT with individual therapists, but this class is not suitable for them. I did not participate in this section.

Patients with a history of trauma, if they feel it is unsafe for them to participate in the guided relaxation exercises in a group setting. Didn't do this one either.

Re: From an email to that neurologist:

Someone asked me why guided relaxation was not recommended for people with trauma. I had some words that might be relevant to other people as well.

Guided relaxation means making yourself vulnerable to a source that's at best untrusted, or at worst actively hostile. It means lowering your defenses and voluntarily cooperating with (and thereby letting in) inputs that could be misguided and damaging, or hostile and damaging.

Pre-recorded guided relaxation *might* be safe if it's pre-screened for safety, and is found to not contain anything that would be unsafe in an unguarded moment, but there's the challenge of listening to such things all the way through and *not* being lulled by them.

Someone with relevant trauma might be able to assemble a DIY guided relaxation thingy based on common elements found in relaxation tapes, so they'd know exactly what was in it, and only listen to it while in a safe environment. Because letting your guard down when you're in a hostile environment is of course unsafe.

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This is a prime example of why CBT is so, so bad for anybody with a trauma history. My thoughts aren't the problem, it's my body literally trying to protect me by telling me a situation is unsafe. (Which is why I have insomnia -- I spent my childhood being forced by an abusive parent to go to bed when I wasn't tired, and in fact, not actually experiencing sleepiness partly because of that and partly because my body pretty much shut off any awareness of internal senses because that was too dangerous to have in the situation I was in. Telling myself to think better thoughts won't fix it, it'll just cause more shame because I can't perform.)

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Thank you. I've been poking around thoughts similar to this lately - I believe I could theoretically do CBT w/ a trusted professional, if I met a professional I could trust to a very high degree, but the basic framing/concept behind CBT comes across to me as gaslighting. It isn't that I don't have cognitive distortions (even ones I'm aware are exactly that), but if somebody is going to poke around in my head *looking for evidence that my brain is distorting things,* I have to trust them to be *not looking for a way to gaslight me and blame all my woes on me in order to excuse the rest of society,* and that just is not an easy trust to win, considering.

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It's possible that you in specific might be able to locate a professional and do work on known distortions first, and poke around looking for more cognitive distortions later, after the first ones go okay (assuming it goes okay).

Like, I assume you've been trying to radio-tag your brainweasels... and what is weasel-stomping but feral CBT?

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Yeah, but there's an enormous difference between *me* (or, say, *you*) saying "that is a weasel, sp. Mustela cerebris," and some person who hasn't earned that level of trust doing it, thinking that having a degree entitles them to that level of trust.

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The idea would be to locate someone with a degree, and go "This is a weasel, Mustela cerebris ssp. androgynae (or whatever); I've radio-tagged it, but I need some help actually *catching* the sucker. What do you think would work?" And depending on how well they proposed handling it (nets? traps? explosives?) they might or might not be allowed the chance to help catch it, and if the catching went well according to their plan, they might maybe be offered the chance to identify other weasels in the future. Because a degree and a Field Guide to the Weasels of North Geekorama does not actually qualify you to identify sithjawa's weasels... and some of them are Mustela putorius furo and should not be mistaken for the other kind!

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The other thing I do with professionals who I semi-trust is bring them uncharacterised possible-weasels and ask for help with identification of said creature. How they do with this task tells me a LOT about their trustworthiness and whether they should be trusted with future situations.

It also lead me to the very odd realisation that my current therapist has more trust in me than I have in me which is ... a very odd feeling. It's nice though.

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YES! AND FOR ANOTHER THING ABUSERS ~UNIVERSALLY IMPOSE THEIR JUDGMENT ON THEIR VICTIMS AND DEMAND THEIR VICTIMS FORFEIT THEIR OWN JUDGMENT IN FAVOR OF THEIR ABUSERS'. ALL COGNITIVE BEHAVIOR TWATWASH RECAPITULATES THE FUNDAMENTAL DYNAMICS OF CHILD ABUSE AND SPOUSAL ABUSE: THAT OF AN AUTHORITY FIGURE ON WHICH ONE DEPENDS FOR CARE TELLING YOU THAT YOU MUST GIVE UP YOUR OWN UNDERSTANDING OF YOUR MIND IN FAVOR OF THEIRS TO RETAIN THEIR APPROVAL. IT IS POSSIBLE TO DO CBT WITH SURVIVORS OF ABUSE AND HAVE IT NOT RETRAUMATIZE THEM BUT THAT IS NOT THE WAY TO BET.

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I agree -- CBT feels like self-gaslighting to me. I didn't even cover the whole element that tends to come up in CBT workbooks of "you can be happy no matter what the external circumstances in your life", which sounds awfully close to telling people that injustice wouldn't make them unhappy if they just stopped disliking it.

There are therapists who do CBT (usually not exclusively CBT) who can be helpful, but that's because therapy has more to do with the nature of the relationship between you and your therapist than it has with theory.

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I had in fact done sleep-related CBT, not realizing what I was doing!
Except instead of bullshit like "This class has helped most others, so it
will help me", it was stuff like "I am not a bad person because I need
sleep", and "A safe amount of sleep is more important than a social event,
and I should not feel excessively guilty for making that decision" and
such. Because I was going after the guilt about caring for myself like I am
a person who matters, and not trying to dismantle the things that have kept
me safe.

The affirmations for someone with a history of trauma are so radically
different. At one point in their messy breakup (which is still not fully
finished) my partner was trying to tell themselves that they would be okay.
That was way too positive an affirmation for someone with that trauma
history, and it was making things worse. "I probably won't die if I go to
game night" was better. "My partner doesn't hate me" was true, but not
related to the problem. "My ex's firearms are in the possession of a third
party" was helpful. And so on.

Even the not-traumatized members of this class would probably have been
better served by affirmations like "That is a work problem, and I can think
about it when I am at my desk" rather than "I will perform just fine even
if I am only allowing myself to stay in bed for four hours."

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There were aspects of CBT approaches that I found very useful, even while being actively (re)traumatized. They let me stop the thought-spirals and helped me accurately assess consequences and evaluate situations. I'm finding that it doesn't get to the underlying masses of shame-guilt-grief-fear, but it's helped me stop getting stuck in them in the moment and has given me some very useful skills.

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>> Even the not-traumatized members of this class would probably have been better served by affirmations like "That is a work problem, and I can think about it when I am at my desk" rather than "I will perform just fine even if I am only allowing myself to stay in bed for four hours."

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"I know you're not getting enough sleep! You can't possibly be getting SO little sleep that you're unsafe to drive, or you can't be working in a creative/information field, or a customer service field, that requires you to be creative or pleasant! So go ahead and force yourself out of bed no more than a half-hour after the duration of whatever sleep you've been managing to catch! Nothing will go wrong, and your body will probably let you safely stay awake until bedtime tomorrow (if you force yourself to, but that should be easy) and then you'll start sleeping better!"

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Even the not-traumatized members of this class would probably have been better served by affirmations like "That is a work problem, and I can think about it when I am at my desk" rather than "I will perform just fine even if I am only allowing myself to stay in bed for four hours."

Ah, but that won't work! See, CBT-I's secret sauce is to use high levels of sleep deprivation to force sleep episodes. So if you don't sell the marks patients on the idea that the feather will make them fly they don't need sleep, how will you convince them that only sleeping hour hours a night is adequate?

CBT-I is two tablespoons of useful sleep hygeine mixed in a pound of patient-shaming and gaslighting: It's not that you can't sleep as much as you need, it's that you don't need as much sleep as you think you do. Your body will always sleep the amount you need, there is no such thing as a sleep disorder. If you think you're exhausted and under-rested after sleeping, that's because you're a whiner.

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I swear to ghu this is true: I was referred to a neurologist sleep specialist because I had been on a medication that massively screwed up my biological ability to sleep. He recommended CBT-I to me. And then said, "Okay, why is it that whenever I recommend CBT to one of you psychotherapists, you all get that look?"

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Sleep restriction[5] is probably the most controversial step of CBT-I, since it initially involves the restriction of sleep. Insomniacs typically spend a long time in bed not sleeping, which CBT-I sees as creating a mental association between the bed and insomnia. The bed therefore becomes a site of nightly frustration where it is difficult to relax. Although it is counterintuitive, sleep restriction is a significant and effective component of CBT-I. It involves controlling time in bed (TIB) based upon the person's sleep efficiency in order to restore the homeostatic drive to sleep and thereby re-enforce the "bed-sleep connection".[6] Sleep Efficiency (SE) is the measure of reported Total Sleep Time (TST), the actual amount of time the patient is usually able to sleep, compared with his or her TIB.

[...]

This process may take several weeks or months to complete, depending on the person's initial Sleep Efficiency and how effective the treatment is for them individually. Daytime sleepiness is a side-effect during the first week or two of treatment, so those who operate heavy machinery or otherwise cannot safely be sleep deprived should not undergo this process.

Allow me to cut through the TLAs and make this clear: if you can only get four hours sleep a night but it takes you two hours to fall asleep, CBT-I requires you to only spend four hours and 20 minutes in bed each night – waking up and getting out of bed after two hours, if it took you two hours to fall asleep – until you become so exhausted that you fall asleep promptly whenever you go to bed, and get the four hours you can in the window you've allocated.

The assumption being there will come a point when you are so exhausted that you will fall asleep in less than 20 minutes.

Cognitive therapy[4][8][9][10] within CBT-I is not synonymous with versions of Cognitive Behavioral Therapy that are not targeted at insomnia. When dealing with insomnia, cognitive therapy is mostly about offering education about sleep in order to target dysfunctional beliefs/attitudes about sleep.

[...] For instance, many insomniacs believe that if they don't get enough sleep they will be tired the entire following day. They will then try to conserve energy by not moving around or by taking a nap. These responses are understandable but can exacerbate the problem, since they do not generate energy. If instead a person actively tries to generate energy by taking a walk, talking to a friend and getting plenty of sunlight, he or she may find that the original belief was self-fulfilling and not necessarily true.

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"many insomniacs believe that if they don't get enough sleep they will be tired the entire following day"

I WONDER WHY THAT COULD BE

I WONDER WHAT COULD HAVE LED THEM TO BELIEVE THAT

I'm like, I can see the logic, and I can see that there might be people this could work for. I can't imagine that there are that many of them (especially as a car really ought to count as heavy machinery).

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I will, in fact, do the thing where I short myself on sleep (but within *usually safe for me* limits, not the specific time in bed and not the same-time-every-day unless the job demands it) in order to reset my sleep schedule, but I ALSO DON'T PRETEND THAT I CAN FUNCTION WHILE I'M DOING IT.

FOR FUCK'S SAKE THIS IS WHY I'M NOT ALLOWED MORE THAN 33% RESPONSIBILITY FOR AN INFANT. WHICH MAY WELL WIND UP BEING SOMEWHAT OF AN ISSUE IN MY RELATIONSHIP, POTENTIALLY.

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FUNNILY ENOUGH, RESTRICTING SLEEP AND THEN STAYING AWAKE UNTIL NORMAL BEDTIME GENERALLY MEANS THAT MY EXECUTIVE FUNCTION HAS ALREADY FUCKED OFF TO SLEEP AND THUS I CANNOT ACTUALLY PERFORM THE CHAIN OF ACTIONS THAT LEADS TO GETTING INTO BED WITH ANY DEGREE OF RELIABILITY. SO I STAY UP EVEN LATER PLAYING BEJEWELED LIKE A ZOMBIE. THAT CAN REPEAT FOR SEVERAL DAYS UNTIL I HIT THE POINT OF 12-16 HOUR MANDATORY SLEEP FROM WHICH THERE IS NO ROUSING ME. OR UNTIL I'VE HIT ABJECT TERROR BECAUSE OF OUR OLD FRIEND SUICIDAL IDEATION.

SOMEHOW I DOUBT THESE FUCKERS WANT TO TAKE ME INPATIENT, BECAUSE THAT'S THE ONLY LEVEL OF SUPERVISION WHERE I'M WILLING TO TAKE ON THAT LEVEL OF SLEEP DEP. AND THAT SOUNDS GENUINELY HELLISH AND ALSO EXPENSIVE.

OR MAYBE I COULD TAKE A NAP. OR STAY IN BED UNTIL I'M RESTED. THOSE THINGS WOULD BE GOOD TOO.

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I haven't read all of this post (i...had insufficient sleep last night after a very stressful day, and am getting ready to go out and conduct a research interview for my PhD project on fatigue and sleep in chronic illness...) but reading the bottom few paragraphs is causing me to the feel the metaphorical flames of RAGE on the side of my face.

re what he recommended to keep you awake when the sleep pressure is high but it's a bad time for a napi'm just...the next time someone tells me that maintaining a 'normal' sleep schedule is Of Utmost Importance, i'm going to thank them profusely and express how extremely GENEROUS it is of them to take on board supporting me financially and physically while i spend this time utterly useless for getting anything done other than Attempting to Maintain Normal Sleep Schedule. I am so very done.

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Thankfully my actual sleep specialist is not someone who would ever make such a ridiculous suggestion, although he is, to my mind, perhaps overconfident at my ability to fall asleep on schedule, even with pharmaceutical assistance.

[I'm about to attempt the latest round of shifting my sleep cycle back so that it both starts and finishes earlier. I actually had to wait to start the attempt, because during the teaching part of semester (Which just finished), i had to get up by 8 or 9am quite often, which i am not supposed to do while i'm shifting my sleep schedule (which is currently more like 3am-11am, if left to its own devices). I'm supposed to let myself sleep until 11am until i am actively working on shifting it!!]